Physician and Nurses' Knowledge and Use of Natural Family Planning

Richard J. Fehring
Marquette University
Nursing Faculty Research and Publications Nursing, College of
Reproduced with Permission

Abstract: Perinatal health professionals are in key positions to either promote or dissuade the use of Natural Family Planning (NFP). The purpose of this article is to describe a survey conducted with perinatal physicians and nurses on their knowledge and professional use of NFP. Four hundred and fifty physicians and nurses (150 MDs and 300 RNs) were sent a questionnaire on the use of and knowledge of NFP. One hundred sixty-six (or 37%) returned the completed questionnaires. Fifty-two percent of the nurses who returned the questionnaires and 48% of the physicians indicated they were taught about NFP in basic (generic) medical or nursing school. The average lecture time spent on the subject in either nursing or medical school was less than one hour. The majority learned about NFP through self-education or on-the-job training. Only four (1 RN and 3 MDs) are certified to teach NFP. Fifty-three percent of the nurses and 44% of physicians would not advise the use of NFP to avoid pregnancy. The most frequent reasons given for not promoting the use of NFP to either avoid or achieve pregnancy were that it is not effective, not natural, too difficult to learn, better methods are available, and it only works for highly motivated educated women.

Very few married couples in the United States (about 2% of all married women) use Natural Family Planning (NFP) as a means of family planning.1 Part of the reason that NFP is not used by more couples might be that persons in influential positions (i.e., physicians, nurses, and clergy) do not promote the use of NFP. Physicians and nurses, particularly those in the perinatal area, are in key positions to influence a woman's/couple's decision in choosing a method of family planning. Although the decision of what method to use to avoid or achieve pregnancy is the woman's or couple's, perinatal health professionals can and do recommend family planning methods. If physicians and nurses were never taught the use of NFP, if they were taught NFP in a cursory manner, if they believe that NFP is ineffective, and/or they were taught that NFP is not an appropriate method for family planning then you would not expect them to promote the use of NFP.

The purpose of this article is to report the results of a survey conducted to determine the knowledge and professional use of NFP by physicians and nurses in the perinatal area.


A simple two page questionnaire was developed by the author to determine if physicians and nurses learned NFP in basic medical and nursing programs, how they learned NFP, and how they currently use NFP in practice. The questionnaires were mailed anonymously to all 150 physicians and 300 nurses who had attended a large preinatal health conference located in a Midwestern state. One hundred and sixty-six respondents (48 physicians and 118 nurses) or 37% returned the questionnaire. No follow-up reminders were sent to the non-respondents. The physician responders (all MDs) were 31 male and 17 females, their average age was 39.8 years (range 27-67), and the majority (85%) graduated from medical school since 1970. The nurse responders were all females, their average age was 38.7 years (range 23-63), and 80% graduated from a basic nursing program since 1970. The sample represented graduates from 20 different medical schools and 30 different nursing programs.


There were two parts to the questionnaire. The first part was to determine how the health professional learned about NFP and the second was to determine how the health professional used NFP in practice.

How NFP Was Learned

Five basic questions were asked in this section. Some of the questions had sub-questions in order to refine the answers. The five questions:

The answers to these questions are found in Table 1.

Greater than 50% of the physicians and almost 50% of the nurses who responded to this survey did not learn about NFP in their generic program. These percentages do not change according to the year of education. The majority who did learn about NFP received the information in a lecture and textbook format. The average time spent on the information in the lecture was an hour or less and what was read in the textbook was a few paragraphs or less. The predominant methods learned in the generic programs were rhythm or basal body temperature (BBT). A majority (greater than 80%) of both physicians and nurses learned about NFP outside of their basic program. The majority did so through on-the-job training and self-education.

How NFP Is Currently Used

There were six questions to determine how NFP was currently used by health professionals to practice.

The answers to these questions are found in Table 2.

A majority of the physician responders indicated they currently use NFP in their practice but only 24% of the nurses. The most frequently utilized methods were the older rhythm/calendar and BBT methods. Only 4 of the 48 physicians and 1 of the 118 nurses were certified to teach NFP. Less than half of the physicians (48%) and nurses (37%) would recommend the use of NFP to avoid pregnancy. However, 90% of the physicians and 64% of the nurses would recommend use of NFP to achieve pregnancy. If a client/patient wanted to use NFP, the majority of physicians would teach her themselves and would provide reading materials and a BBT thermometer. A majority of nurses would provide reading material and/or refer to a qualified NFP teacher.

The respondents were also provided space on the questionnaire to comment on NFP and to provide reasons why they would not advise the use of NFP. The most frequent categories were: NFP is unreliable to prevent pregnancy; it should be used only by motivated and educated people; the methods are too difficult to learn; people prefer to use simpler methods; and that NFP is unnatural. A number of respondents indicated that they were not familiar with the methods. Others did not feel that the methods were applicable to their job. Some of the respondents indicated that they have personally used NFP satisfactorily and that they would like to learn about the methods.


Based on this survey, the information provided physicians and nurses on NFP in basic education is either absent, out-of-date, or cursory. Although the majority of perinatal physicians and nurses eventually learned about NFP, they did so by self-education and/or on-the-job training. Many of the physicians and nurses were only familiar with or used the older methods of NFP. Although only 5 of the 166 physician and nurse respondents were certified to teach NFP, many indicated they provided NFP services to clients by handing them reading material and a BBT thermometer. This response from the health professionals reflects the treatment of NFP as a contraceptive (pill or device) that can be provided by a prescription rather than by an educational process. To properly teach NFP takes time and professional qualifications. Providing a health care service without knowing how to properly provide it reflects the general lack of knowledge of NFP and the lack of respect given to this mode of family planning. This behavior could contribute to women and couples not receiving proper instructions in NFP and not being successful in achieving or avoiding pregnancy.

The answers to this survey also reflect the negative biases and prevalent myths of NFP in the health care professions. Most of the perinatal physician and nurse respondents would not recommend the use of NFP to avoid pregnancy because they felt that it was unreliable, unnatural and should only be used by intelligent, educated, and motivated people. These are common misconceptions about NFP. Studies have repeatedly shown that when NFP is taught by qualified practitioners (and in a standardized way) it is a highly effective way to avoid pregnancy.2,3,4 The data from the five-country World Health Organization (WHO) (1991) study on the effectiveness of the ovulation method to avoid pregnancy revealed a 2.8% method effectiveness.5 Although the use-effectiveness of the method was approximately 20%, over 15% of those pregnancies were conscious departures from the rules, i.e., the couples knowingly used the method in a way to become pregnant on a fertile day and did become pregnant. Another interesting fact about the WHO study was that after only three teaching cycles over 90% of the women had an excellent or good grasp of the method and were able to identify their fertile period. Many of the subjects in the WHO study were illiterate or had very little schooling. In fact, the effectiveness rates from the subjects in the developing countries were better than those from the developed countries.

The problem of motivation in the use of NFP was frequently mentioned by the respondents. Motivation is an important behavioral factor with other methods of family planning, be it the pill, condom, or diaphragm. Part of the responsibility of a health professional is to help clients with motivation. The fact that NFP is a method of family planning that is taught to couples over a period of time probably enhances user motivation. This might account for the fact that over 64% of the subjects in the WHO study continued to use the ovulation method of NFP after a 13 month period. A recent study by Fehring, Lawrence and Philpot found a 78% continuation rate over 12 ordinal months with 242 couples using the ovulation method.4 If health professionals do not encourage and support the use of NFP then you would expect couples to find reasons to discontinue use.


Since health professionals are provided little information about NFP, and since nurses and physicians are providing NFP without proper qualifications or training, somehow health professionals need to receive information about NFP from knowledgeable sources. Health professionals need to know about modern methods of NFP and the proper qualifications to provide NFP services. An ideal setting for a NFP teacher training program would be a (Catholic) medical or nursing school. The closest to this ideal is the NFP educational program at the Pope Paul VI Institute for the Study of Human Reproduction that is affiliated with Creighton University.

Professional NFP organizations (such as the American Academy of NFP) could provide medical and nursing programs expertise and materials on NFP. They could monitor medical and nursing textbooks and recommend texts that provide an unbiased factual presentation of NFP. They could work with professional medical and nursing organizations and provide programs on NFP at their conferences and annual meetings. Service settings could also be made aware of the standards of practice and provision of NFP services and be encouraged to meet them.

Although this survey reflects responses from a sample of perinatal nurses and physicians, the results do provide some insights into the state of knowledge and use of NFP by health professionals. The survey responses reflect a lack of knowledge, improper use, and non-use of NFP. The responses also provide some understanding of why only 2% of women in the United States use modern methods of NFP. A recommendation for further assessment of the use of NFP by health professionals would be to develop a questionnaire that is a knowledge test of NFP that includes the perceived effectiveness of the various methods. The survey could be directed to a random selection of health professionals in the area of family planning. These individuals are directly involved in providing family planning services and should have direct knowledge of methods of NFP and should be able to provide a perspective of practical interest.



The author is Associate Professor, Marquette University College of Nursing


Table 1: How NFP Was Learned

Table 2: How NFP Is Currently Used